A cervical myelogram is the radiographic visualisation of the cervical spinal cord subdural space following the injection of a contrast media agent into the cerebrospinal fluid within the subdural space.

• neck and arm pain and weakness
  
• most commonly performed today on patients who are unable to have MRI assessment of their spinal cord
  

• non-consent by patient to procedure
• contrast or iodine allergy
• pregnancy (pregnancy test compulsory for women of child-bearing age in some centres)
• bleeding disorders, blood thinning medications , anticoagulants (heparin, warfrin, aspirin)[ check I.N.R. if available]
• arachnoiditis
• abnormal ICP
• blood in CSF

• patient identification (3 Cs- correct patient, correct side, correct procedure)

• Patient should be wearing a hospital gown; pants,socks and shoes removed
  
• consent form
• Fast from solids for 4 - 6 hours prior to procedure
  
• collect relevant previous imaging for ease of access prior to procedure
• A premed of 10mgs of oral valium will reduce patient anxiety levels
• injection site shaved as deemed necessary
• advise the CT scanning radiographer when you are about to start the procedure (patient will be sent to CT for a CT myelogram after the procedure)
• patient should empty bladder prior to teh procedure
• ensure lab form is completed
  

1	21 gauge 3/45 inch butterfly needle
2	25 ml syringes
1	drawing up cannula
1	swab
1	tape
1	20 ml normal saline in 25 ml syringe
2	tourniquet

Preparation	Cervical myelography is best performed as a fluoroscopy procedure using a C-arm unit contrast media is commonly injected at the level of lumbar L2/3 or L3/4 level Contrast media can be injected directly into the subdural space at the cervical level if required obtain consent and explain procedure to patient cervical preliminary/scout images should be taken (AP, lateral, swimmers)
Direct Cervical Injection	Position the patient prone on the fluoroscopy table with their feet on the footplate. A sponge under the patients feet will improve patient comfort The patient's neck is extended and placed on a foam block. The patient should be asked at this stage whether they will be able to tolerate this position for the length of the procedure (at least 1/2 hour) The patient's arms should be immobilised at his/her sides with straps and the patient should have handgrips positioned at a comfortable level. rotate the C-arm into the cross-table lateral position and centre to the C1/C2 level- ensure the patient's cervical spine ios perfectly lateral. a pair of forcepts and a black felt-tip pen will be used by the radiologist to mark a spot on the skin for needle placement. This point will be between the first and second cervical vertebra spinous processes and at the level of the lower 1/3rd. the radiologist will apply a skin prep and the patient will have a drape covering applied. the radiologist will inject local anaesthetic at the needle entry site. The radiologist will insert the 22 guage spinal needle into the subdural space and manipulate the needle until cerebrospinal fluid (CSF) is seen to drip from the needle when the stylet is removed. CSF is collected for laboratory analysis 8 - 10 mls of contrast media is injected into the subdural space. Select a larger field of view such that the patient's clivis is visualised. Screen while the contrast is injected to ensure that it remains within the cervical lordosis. tilt the table as required to keep the contrast media in the cervical lordosis. Care must be taken at all times to ensure that the contrast media does not spill into the cranial subdural space.ventricles the spinal needle is removed by the radiologist ready for imaging
Lumbar Injection
Imaging	The radiographer must ensure that the contrast bolus remains within the cervical region during imaging. All of the contrast can be lost to the cranial subdural space very quickly if sufficient care is not taken. Imaging is as follows lateral with traction on patient's arms AP Coned AP of foramen magnum 30 and 55 degree obiques Swimmers lateral with C1 included in image Ap and obliques of cervico thoracic junction is required All images should have a landmark reference- either C1 or the first rib The patient should have CT myelogram imaging within 2 - 3 hours

"The most important limitation of myelography is its inability to visualize entrapment of the nerve root lateral to the termination of the nerve root sheath. It is thus unable to detect any far lateral disc herniations." (AMERICAN FAMILY PHYSICIAN, JUNE 1, 2002 / VOLUME 65, NUMBER 11 www.aafp.org/afp p 2303

• imaging must occur immediately after contrast injection because contrast is absorbed quickly

• dural tear
• headache
• infection
• oNerve root damage
  oMeningitis
  oEpidural abscess
  oContrast reaction (anaphylactic shock)
  oCSF leak
  oHemorrhage

• rest and increased fluid intake will help to reduce headaches post myeolgram
• nMonitoring required
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  nHead and shoulders elevated 30 to 45 degrees
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  nBed rest for several hours
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  nFluid encouraged
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  nPuncture site checked before release